- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $562.34 / $870.96
| Professional | | $446.68 | $562.34 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,412.54 / $1,905.46
| Professional | | $933.25 | $1,412.54 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,047.13 / $1,862.09
| Professional | | $645.65 | $1,047.13 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $10,471.29
| Facility | | $2,630.27 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,000.00 / $2,089.30
| Professional | | $575.44 | $1,000.00 | $2,089.30 |